AAP report educates providers on alternative birth practices

A new AAP report describing seven alternative birth practices and the risk for infection in exposed newborns was compiled to help educate providers who may be asked to counsel expectant or new parents, the AAP said.

Co-author Dawn Nolt, MD, MPH, a professor of pediatrics in the division of infectious diseases at the Oregon Health and Science University School of Medicine, said pediatricians have requested more information on the practices.

“We were just getting requests from pediatricians on what these practices were and how they should counsel families interested in these practices on the risks and benefits,” Nolt told Healio. “We also [want] to raise awareness that there was risk of infection if someone engages in these practices.”

Nolt and colleagues identified seven alternative birthing and labor practices: water birth, vaginal seeding, umbilical cord nonseverance, placental consumption, nonmedical deferral of birth hepatitis B virus vaccination, deferral of ocular prophylaxis, and delayed bathing.

“We looked at medical literature to see if there was any scientific basis for any purported risks or benefits to either the mom or to the newborn,” Nolt said. “We wanted to give pediatricians an overview of these practices so that, really, they feel comfortable talking to parents about this. And if they are confronted with a sick infant, in whom the birth family has engaged in these practices, to be aware of any subtle changes in terms of testing or treatment that they may need to employ for the child, because some of those practices raise infection risk, perhaps from bacteria that are not normally considered when a pediatrician is caring for a sick child.”

The report said providers should discourage the deferral of hepatitis B vaccination, which “serves as a critical safety net for prevention of HBV infection in situations in which the records of the pregnant person are never obtained, ignored, incorrectly transcribed, misinterpreted, or falsely negative, such as may occur with acquisition of HBV infection late in pregnancy after a negative initial test result.”

For water births, the authors noted that although birthing centers increasingly have birthing tubs — and there is increased interest for hospitals to have such tubs for labor — no data were available on the exact number of water births that occur in the U.S.

“Immersion during the first stage of labor has been shown to decrease the use of regional anesthesia but had no impact on mode of delivery, although overall cesarean rates were low for all groups in the studies,” they wrote. “During the second stage of labor, water immersion did not show any benefits, nor any differences in outcomes, for the pregnant individual.”

The report noted that a 2014 recommendation from the AAP and the American College of Obstetricians and Gynecologists acknowledged the maternal benefits of water immersion during the first stage of labor but cautioned against the use for the second stage of labor or during delivery because of insufficient current evidence of benefit and rare but serious neonatal complications, including hypothermia, drowning or near-drowning, respiratory distress and infections caused by waterborne pathogens, such as Legionella.

Placental consumption, which the authors noted is “observed in nonhuman mammals, presumably to avoid predators, to keep the nesting area clean, and to nourish the mother,” “was an interesting topic to review,” Nolt said.

Like water births, the authors noted that although “there are purported maternal benefits of placentophagy, including decreased postpartum depression, increased breast milk production, improved iron status, reduced postpartum pain, decreased uterine bleeding and a general increase in energy,” there have been no human studies regarding these benefits, outside of self-reported surveys.

The report concluded that although water immersion has been shown to comfort the pregnant person in the first stage of labor but has not shown benefits in the second or delivery stages, placentophagy “should be avoided because there is no evidence of benefit to the caregiver.”

Nolt added that the report showed that more long-term studies were required regarding these alternative practices to better find any benefits or risks to new mothers or their infants.

“Many of these practices have benefits that are outlined by surveys, by self-reported outcomes. They're not very rigorous,” Nolt said. “And so, if we're going to try to integrate any of these practices, we really need comparative studies with some long-term observation.”

“I think we as providers should be empathetic and compassionate to families who have different belief systems than we do,” Nolt said. “We should, you know, outline what the evidence is and have a frank conversation but also acknowledge that, in the end, it is the birth family that decides how their baby is born.”